Malaria in pregnancy: a literature review

Pregnancy outcomes following surgical repair of female genital fistula in Uganda

Background

Women developing genital fistula and undergoing fistula repair in sub-Saharan Africa and South Asia are largely of reproductive age, and fistula prevalence is highest in countries with high fertility and where social values are placed on childbearing. Optimizing women's health following female genital fistula and surgical repair requires further understanding of the risks to subsequent pregnancies and how to mitigate them, to enable women to achieve their desired family size without additional morbidity.

Objective

We sought to contribute to the postfistula repair evidence base through estimating rates of spontaneous abortion and stillbirth as well as the associated risk factors of these adverse outcomes in pregnancies following fistula repair.

Methods

We captured data on sociodemographic characteristics, obstetric and fistula history, and pregnancy and childbirth care and experiences, and outcomes for the first postrepair pregnancy from 302 women who became pregnant within 10 years following genital fistula repair, recruited from six fistula repair facilities in Uganda. We described sociodemographic characteristics, spontaneous abortion (pregnancy loss <20 weeks gestational age), and stillbirth (intrauterine fetal death at ≥20 weeks gestational age) and determined factors associated with these outcomes using logistic regression. We compared outcomes to two external data sources: a meta-analysis and propensity-score matched Ugandan women of reproductive-age.

Results

Overall, 14% (43/302) of the participants had spontaneous abortions and 5% (12/255) had stillbirths in postrepair pregnancies. The spontaneous abortion rate in our study was higher compared to a recent meta-analysis; however, the stillbirth rate was not. The stillbirth rate in our study was 2.5 percentage-points higher compared to the general population (95% CI 0.2-4.9, P=.036). Factors independently associated with increased risk of spontaneous abortion included fistula type, vaginal bleeding during pregnancy, any urine leakage, and educational attainment. Vesicovaginal fistula (VVF)-high (VVF types I and III) vs VVF-low (VVF type II Aa Ab Ba Bb) had significantly reduced odds of spontaneous abortion (adjusted odds ratios [aOR] 0.11, 95% CI 0.03-0.45, P=.002) and rectovaginal fistula and VVF-other (other or not indicated) had marginally reduced odds (aOR 0.38, 95% CI 0.012-1.14, P=.083 and aOR 0.26, 95% CI 0.05-1.25, P=.093, respectively). In bivariate analyses, any urine leakage, assisted vaginal delivery, and emergency cesarean section were highly correlated with stillbirth. Stillbirth risk was over-10-fold higher among individuals reporting urine leakage (OR 10.5, 95% CI 2.75-20.43, P=.001). Assisted vaginal birth and emergency cesarean birth were both associated with 17-fold increased odds of stillbirth (OR 16.93, 95% CI 1.45-198.08, P=.024 and 16.56, 95% CI 1.65-166.28, P=.017, respectively).

Conclusion

Our results demonstrate that in the study setting, greater attention to high-quality, comprehensive pregnancy care and birth planning are critical for improving outcomes among women who have undergone fistula repair, including facilitation of elective cesarean section which is recommended for postrepair births. Additional investments must be made to strengthen women's health access and knowledge that supports their postfistula repair reproductive goals.

Risk factors for anaemia among pregnant women: A cross-sectional study in Upper East Region, Ghana

BACKGROUND

Anaemia in pregnancy (AIP) is a public health concern due to its devastating effects on women and their unborn babies, resulting in increased maternal and neonatal deaths in developing countries. Despite several Ghanaian health policies to combat AIP, AIP is still on the rise. It becomes imperative to identify geographic-specific factors for developing appropriate interventions for the management of AIP. However, Kassena Nankana West District (KNWD) in the Upper East Region of Ghana lacks a study on anaemia risk factors, therefore, this study estimated the prevalence and risk factors for anaemia among pregnant women in the district.

METHODS

A cross-sectional study was conducted from February to March 2023 in the KNWD. Approximately 376 pregnant women in their third trimester were randomly selected from 10 health facilities by utilizing the antenatal register as the sampling frame. Anthropometric, obstetric, sociodemographic, and health facility resource characteristics were collected using structured questionnaires and from antenatal records. Mixed-effect logistic regression was used to identify independent factors of anaemia at 95% confidence interval.

RESULTS

Prevalence of AIP was 53.9% (95%CI:48.5%-58.8%). Mild, moderate, and severe anaemia prevalence was 16.9%, 35.3%, and 1.7% respectively. Malaria infection during pregnancy (aOR = 1.64; 95%CI:1.03-2.62) and accessing health facilities without trained laboratory personnel (aOR = 5.49; 95%CI:1.67-18.00) were associated with increased odds of AIP. Belonging to the major ethnic group (aOR = 0.52; 95%CI:0.28-0.85), accessing health facilities without laboratory services (aOR = 0.14; 95%CI:0.04-0.47), and accessing health facilities without sulphadoxine-pyrimethamine drugs (aOR = 0.22; 95%CI:0.06-0.86) in KNWD were also associated with decreased odds of AIP.

CONCLUSION

KNWD has a severe burden of AIP. Maternal and health facility-related factors were associated with AIP in the district. These factors are preventable. Therefore, the provision of functional laboratory services with dedicated technical personnel, regular supply of sulphadoxine-pyrimethamine drugs to the health facilities, and enhanced community education on malaria prevention are recommended for anaemia control in the district.

The relationship between anaemia and the use of treated bed nets among pregnant and non-pregnant women in Ghana

Studies have indicated that the risk of malaria, particularly its association with anaemia in pregnant women, increases when treated bed nets are not used. This paper utilizes a statistical mechanical model to investigate whether there is a statistical relationship between the presence or absence of anaemia in pregnant and non-pregnant women and their decision to sleep under treated bed nets. Data from the Ghana Malaria Indicator Survey (GMIS), which includes both rural and urban malaria-endemic areas in Ghana, were employed in this study. A total of 2,434 women, comprising 215 pregnant and 2,219 non-pregnant participants, were involved. Among these, 4.76% of the pregnant and anaemic women and 45.89% of the non-pregnant and anaemic women slept under treated bed nets, while 0.86% of the pregnant and anaemic and 6.82% of the non-pregnant and anaemic women did not. The findings revealed that, in the absence of social interaction, non-anaemic pregnant women have a lower prevalence of choosing to use bed nets compared to their anaemic counterparts. Additionally, non-pregnant anaemic women showed a positive private incentive (30.87%) to use treated bed nets, implying a positive correlation between anaemia and the choice to sleep in a treated bed net. Furthermore, the study demonstrated that both pregnancy and anaemia status have a relationship with the use of treated bed nets in Ghana, especially when social interactions are considered. The interaction strength between non-pregnant and anaemic women interacting with each other shows a negative estimate (-1.49%), implying that there is no rewarding effect from imitation. These insights are crucial for malaria prevention and control programs, emphasizing the need for targeted interventions to enhance the use of treated bed nets among both pregnant and non-pregnant women in Ghana's malaria-endemic regions.

Nascent pharmacological advancement in adamantane derivatives

The adamantane moiety has attracted significant attention since its discovery in 1933 due to its remarkable structural, chemical, and medicinal properties. This molecule has a notable impact in the therapeutic field because of its "add-on" lipophilicity to any pharmacophoric moieties. As in the case of molecular hybridization, in which one pharmacophore is attached to another one(s) with a probability of increasing the biological activity, adding an adamantane unit improves the absorption distribution, metabolism and excretion properties of the resultant hybrid molecule. This review summarizes various reports highlighting the biological activities of adamantane-based synthetic compounds and their structure-activity relationship study. The information presented in this review may open up possible dimensions for adamantane-based drug development and discovery in the pharmaceutical industry after proper structural modifications.

Malaria in pregnancy in India: a 50-year bird's eye

Introduction

In 2021, India contributed for ~79% of malaria cases and ~ 83% of deaths in the South East Asia region. Here, we systematically and critically analyzed data published on malaria in pregnancy (MiP) in India.

Methods

Epidemiological, clinical, parasitological, preventive and therapeutic aspects of MiP and its consequences on both mother and child were reviewed and critically analyzed. Knowledge gaps and solution ways are also presented and discussed. Several electronic databases including Google scholar, Google, PubMed, Scopus, Wiley Online library, the Malaria in Pregnancy Consortium library, the World Malaria Report, The WHO regional websites, and ClinicalTrials.gov were used to identify articles dealing with MiP in India. The archives of local scientific associations/journals and website of national programs were also consulted.

Results

Malaria in pregnancy is mainly due to Plasmodium falciparum (Pf) and P. vivax (Pv), and on rare occasions to P. ovale spp. and P. malariae too. The overall prevalence of MiP is ~0.1-57.7% for peripheral malaria and ~ 0-29.3% for placental malaria. Peripheral Pf infection at antenatal care (ANC) visits decreased from ~13% in 1991 to ~7% in 1995-1996 in Madhya Pradesh, while placental Pf infection at delivery unit slightly decreased from ~1.5% in 2006-2007 to ~1% in 2012-2015 in Jharkhand. In contrast, the prevalence of peripheral Pv infection at ANC increased from ~1% in 2006-2007 to ~5% in 2015 in Jharkhand, and from ~0.5% in 1984-1985 to ~1.5% in 2007-2008 in Chhattisgarh. Clinical presentation of MiP is diverse ranging from asymptomatic carriage of parasites to severe malaria, and associated with comorbidities and concurrent infections such as malnutrition, COVID-19, dengue, and cardiovascular disorders. Severe anemia, cerebral malaria, severe thrombocytopenia, and hypoglycemia are commonly seen in severe MiP, and are strongly associated with tragic consequences such as abortion and stillbirth. Congenital malaria is seen at prevalence of ~0-12.9%. Infected babies are generally small-for-gestational age, premature with low birthweight, and suffer mainly from anemia, thrombocytopenia, leucopenia and clinical jaundice. Main challenges and knowledge gaps to MiP control included diagnosis, relapsing malaria, mixed Plasmodium infection treatment, self-medication, low density infections and utility of artemisinin-based combination therapies.

Conclusion

All taken together, the findings could be immensely helpful to control MiP in malaria endemic areas.

Burden and seasonal distribution of malaria in Ziquala district, Northeast Ethiopia: a 5-year multi-centre retrospective study

OBJECTIVE

This study was aimed to determine the 5-year trend of malaria positivity rate in Ziquala district, Northeast Ethiopia.

METHODS

Review of blood film reports from health institutions' laboratory record books using predesigned checklists was done as part of an institution-based retrospective study to assess the 5-year (2016/2017-2020/2021) trend of malaria. To display data and analyse patterns in the trend of malaria over the course of years, months and seasons, descriptive statistics were used. The results of the data analysis were displayed in tables and figures using SPSS V.26.0. P values under 0.05 were considered as statistically significant for all comparisons.

RESULTS

A total of 46 365 blood films from malaria suspected individuals were diagnosed using microscopy over the last 5 years. Of the diagnosed individuals, 14 429 (31.1%) were confirmed positive for Plasmodium infection. Plasmodium falciparum (59.7%) and Plasmodium vivax (37.0%) were the dominant species. The positivity rate of mixed infection (P. falciparum and P. vivax) was 3.3%. The maximum (3598; 29.6%) and minimum (2085; 29.1%) number of cases were reported in 2019/2020 and 2020/2021, respectively. Of the total cases, 9206 (63.8%) were in males. Moreover, the highest malaria positivity rate was observed in the age group of 15-45 (4040; 28.0%). Among the six health facilities, Ziquala district hospital had the highest malaria positivity rate (35.8%), followed by Tsitsika health centre (27.3%) and Mishra health centre (14.2%).

CONCLUSION

With P. falciparum being the most common species, malaria remains a severe public health threat in the district. Therefore, the district health office and other concerned bodies should strengthen and implement evidence-based malaria prevention and control measures.

Serum anti-erythropoietin antibodies among pregnant women with Plasmodium falciparum malaria and anaemia: A case-control study in northern Ghana

BACKGROUND

Anaemia in pregnancy is common in underdeveloped countries, and malaria remains the predominant cause of the condition in Ghana. Anti-erythropoietin (anti-EPO) antibody production may be implicated in the pathogenesis of Plasmodium falciparum malaria-related anaemia in pregnancy. This study ascertained the prevalence of anti-EPO antibody production and evaluated the antibodies' relationship with Plasmodium falciparum malaria and malaria-related anaemia in pregnancy.

METHODS

This hospital-based case-control study recruited a total of 85 pregnant women (55 with Plasmodium falciparum malaria and 30 controls without malaria). Venous blood was taken from participants for thick and thin blood films for malaria parasite microscopy. Complete blood count (CBC) analyses were done using an automated haematology analyzer. Sandwich enzyme-linked immunosorbent assay (ELISA) was used to assess serum erythropoietin (EPO) levels and anti-EPO antibodies. Data were analyzed using IBM SPSS version 22.0.

RESULTS

Haemoglobin (p<0.001), RBC (p<0.001), HCT (p = 0.006) and platelet (p<0.001) were significantly lower among pregnant women infected with Plasmodium falciparum. Of the 85 participants, five (5.9%) had anti-EPO antibodies in their sera, and the prevalence of anti-EPO antibody production among the Plasmodium falciparum-infected pregnant women was 9.1%. Plasmodium falciparum-infected pregnant women with anti-EPO antibodies had lower Hb (p<0.001), RBC (p<0.001), and HCT (p<0.001), but higher EPO levels (p<0.001). Younger age (p = 0.013) and high parasite density (p = 0.004) were significantly associated with Plasmodium falciparum-related anti-EPO antibodies production in pregnancy. Also, younger age (p = 0.039) and anti-EPO antibody production (p = 0.012) related to the development of Plasmodium falciparum malaria anaemia in pregnancy.

CONCLUSION

The prevalence of anti-EPO antibodies among pregnant women with Plasmodium falciparum malaria was high. Plasmodium falciparum parasite density and younger age could stimulate the production of anti-EPO antibodies, and the antibodies may contribute to the development of malarial anaemia in pregnancy. Screening for anti-EPO antibodies should be considered in pregnant women with P. falciparum malaria.

Prevalence and associated risk factors of malaria among febrile under-five children visiting health facilities in Ziquala district, Northeast Ethiopia: A multicenter cross-sectional study

BACKGROUND

Malaria is among the leading causes of mortality and morbidity among under five children in developing countries. Ethiopia has set targets for controlling and eliminating malaria through at-risk group interventions. However, the disease remains a serious public health concern in endemic areas like in Wollo, Northeast Ethiopia. Therefore, this study aimed to determine malaria prevalence, risk factors and parasite density among under five children in Ziquala district.

METHOD

A facility-based cross-sectional study was conducted in Ziquala hospital, and Tsitsika, Mishra and Hamusit health centers in Ziquala district, Northeast Ethiopia, from January 2022 to April 2022. The study enrolled a total of 633 under five children using a systematic sampling technique. A capillary blood sample was collected from each child to prepared thin and thick blood smears. Smears were then stained with 10% Giemsa and examined under light microscope. A pretested structured questionnaire was used to collect on socio-demographic data, parental/caregiver knowledge, and malaria determining factors. Bivariable and multivariable logistic regression analysis was done to identify factors associated with malaria.

RESULT

The overall prevalence of malaria among children visiting Ziquala district health institutions was 24.6% (156/633). Plasmodium falciparum, P. vivax, and mixed infection (both species) accounted for 57.1%, 38.5%, and 4.5% of the cases, respectively. Regarding to parasite load, moderate parasitemia was the most common, followed by low and high parasitemia with the proportion of 53.8%, 31.4% and 14.7% parasite density, respectively. Malaria infection was linked to irregular utilization of insecticide-treated bed nets (AOR = 5.042; 95% CI: 2.321-10.949), staying outside at night (AOR = 2.109; 95% CI: 1.066-4.173), and parents not receiving malaria health education in the past six months (AOR = 4.858; 95% CI: 2.371-9.956).

CONCLUSION

Malaria was prevalent among children under the age of five enrolled in the study. The local government should focus on regular insecticide treated net utilization, reducing the risk of mosquito bites while sleeping outdoors at night and increasing public understanding of malaria prevention and control through health education would also help to minimize the burden of malaria.

Prevalence of malaria and associated factors among symptomatic pregnant women attending antenatal care at three health centers in north-west Ethiopia

BACKGROUND

Malaria is the disease caused by Plasmodium species and primarily transmitted by the bite of female Anopheles mosquitoes. During pregnancy, malaria causes life threatening outcomes to the mother, the fetus and the new born. Even though, malaria symptomatic pregnant women highly attract mosquitoes and have higher potential of transmitting the disease in communities, most of the previous studies focused on pregnant women with asymptomatic Plasmodium infections. Therefore, the aim of this study was to assess the prevalence of malaria and associated factors among symptomatic pregnant women attending antenatal care at three health centers in northwest Ethiopia.

METHODS

A health facility based cross-sectional study was conducted from February to April, 2021. A total of 312 malaria symptomatic pregnant women were involved from three health centers and enrolled by convenient sampling technique. A questionnaire was used to collect socio demographic and clinical data through face to face interview. Capillary blood samples were collected and used to prepare thin and thick blood smears, which were then stained using 10% Giemsa and examined under light microscope. Logistic regression was used to assess factors associated with malaria. Adjusted odds ratio with 95% confidence interval was calculated and P-value < 0.05 was considered statistically significant.

RESULTS

The prevalence of malaria among symptomatic pregnant women was 20.8% (65/312) of which 12.2% (38/312), 4.8% (15/312) and 3.8% (12/312) were P. falciparum, P. vivax and mixed infections, respectively. Being illiterate (p< 0.001), first trimester (p = 0.036), primigravidae (p<0.001), living far from health center (p<0.001), not sleeping under long lasting insecticide treated nets (p<0.001) and living near irrigation areas (p = 0.006) were significantly associated with prevalence of malaria in malaria symptomatic pregnant women.

CONCLUSIONS

Even though prevalence of malaria is decreasing in the country because of scale-up of intervention and prevention measures, this study showed that, malaria is still the major public health problem among pregnant women. Being illiterate, first trimester, primigravidae, living far from health centers, not sleeping under long lasting insecticide treated nets and living near irrigation areas were factors that increased the prevalence of malaria in malaria symptomatic pregnant women. Therefore, special attention should be given to pregnant women prone to these factors.

ABO blood group and risk of malaria during pregnancy: a systematic review and meta-analysis

The association between the ABO blood group and the risk of malaria during pregnancy has not been clearly established. The present study summarised relevant knowledge and reassessed the association through meta-analysis. Articles in MEDICINE and PubMed published before 30 November 2021 were searched. Five studies satisfied the inclusion criteria and were enrolled in the meta-analysis. It was shown that primiparae with different ABO blood group, multiparae with blood group A and non-A, AB and non-AB had a comparable risk of malaria. However, multiparae with blood group B had a significantly higher risk than non-B group [odds ratio (OR) = 1.23, 95% confidence interval (CI) was 1.01 to 1.50, P = 0.04], while multiparae with blood group O had a significantly lower risk than non-O group (OR = 0.78, 95% CI was 0.63 to 0.97, P = 0.03). Therefore, the ABO blood group may not result in a different risk of malaria in primiparae. Blood group B is potentially a risk factor while blood group O is a protective factor for multiparae.

Determinants of the uptake of intermittent preventive treatment of malaria in pregnancy with sulphadoxine pyrimethamine in Sabatia Sub County, Western Kenya

BACKGROUND

Annually, 125.2 million pregnant women worldwide risk contracting malaria, including 30.3 million and 1.5 million in Sub-Saharan Africa and Kenya respectively. At least three doses of sulphadoxine pyrimethamine for intermittent preventive treatment of malaria in pregnancy (IPTp-SP) is recommended for optimal benefit. Kenya recorded low IPTp-SP optimal uptake in 2015. This study investigated the prevalence of and factors influencing IPTp-SP optimal uptake in Sabatia Sub County, Western Kenya.

METHODS

A cross-sectional study was conducted in Sabatia Sub County from April to October 2020. Using a validated semi-structured questionnaire, data were obtained from 372 randomly sampled post-delivery women aged 15-49 years with live birth within one year preceding the study. Women on cotrimoxazole prophylaxis during pregnancy were excluded. Pearson Chi-square and Fisher's Exact test were measures of association used. Binary logistic regression analysed predictors of optimal IPTp-SP uptake.

RESULTS

Optimal IPTp-SP uptake was 79.6%, 95% CI 75.5%-83.7%. Predictors of IPTp-SP optimization were gestational age at first antenatal care (ANC) visit (P = 0.04), frequency of ANC visits (P < 0.001), maternal knowledge of IPTp-SP benefits (P < 0.001), maternal knowledge of optimal sulphadoxine pyrimethamine (SP) dose (P = 0.03) and SP administration at ANC clinic (P = 0.03). Late ANC initiators were less likely to receive optimal IPTp-SP (aOR = 0.4, 95% CI 0.2-0.9). Odds of optimizing IPTp-SP increased among women with ≥ 4 ANC visits (aOR = 16.7, 95% CI 7.9-35.3), good knowledge of IPTp-SP benefits (aOR = 2.4, 95% CI 1.3-4.5) and good knowledge of optimal SP dose (aOR = 1.9, 95% CI 1.1-3.4). Women who never missed being administered SP were highly likely to receive optimal IPTp-SP (aOR = 2.9, 95% CI 1.1-7.2) CONCLUSIONS: This study has found high IPTp-SP optimal uptake in the study area. Efforts should be directed towards early and more frequent ANC visits. Intensive and targeted health education is required. It's fundamental to adequately stock and consistently administer SP. Future studies considering larger samples and health workers' perspectives of the health system delivery factors are recommended.

Analysis of Five-Year Trend of Malaria at Bichena Primary Hospital, Amhara Region, Ethiopia

Background

Malaria is a life-threating infectious diseases caused by protozoan parasite of the genus Plasmodium. The WHO African region bears the largest burden of malaria morbidity and mortality every year. Prevention and control activity of malaria in Ethiopia is implemented as guided by a national strategic plan to decrease malaria burden. This study is aimed at assessing the five-year trend of malaria at Bichena Primary Hospital.

Method

A retrospective study was conducted at Bichena Primary Hospital to assess the five-year (2015-2019) trend of malaria by reviewing blood film reports from a laboratory logbook.

Result

In a five-year period, 9182 blood films were requested for malaria diagnosis of whom 53.8% were males and 41% were in the age group 15-29. The overall prevalence of malaria was 9.28% (n = 852), P. falciparum being the dominant malaria species. The highest peaks of total malaria cases were observed in 2016 and in December, and the lowest peaks were observed in 2018 and March (mean annual case 170.4; mean monthly case 14.2), and there was a statistically significant year and monthly variation of malaria cases (P < 0.001). Malaria was reported in both sexes and all age groups; of which, males and the age group 15-29 years old consist the highest number of malaria cases (P < 0.001).

Conclusion

Malaria remains an important public health problem in the study area, and a significant fluctuation was noticed in a five-year period, P. falciparum being slightly the dominant malaria species. Successive efforts are still required to reduce malaria burden to a level that has no longer public health effect.

Components of antenatal care received by women in fishing communities on Lake Victoria, Uganda; a cross sectional survey

BACKGROUND

Uganda has one of the highest maternal deaths at a ratio of 336 per 100,000 live births. As Uganda strives to achieve sustainable development goals, appropriate antenatal care is key to reduction of maternal mortality. We explored women's reported receipt of seven of the Uganda guidelines components of antenatal care, and associated factors in hard to reach Lake Victoria island fishing communities of Kalangala district.

METHODS

A cross sectional survey among 486 consenting women aged 15-49 years, who were pregnant at any time in the past 6 months was conducted in 6 island fishing communities of Kalangala district, Uganda, during January-May 2018. Interviewer administered questionnaires, were used to collect data on socio-demographics and receipt of seven of the Uganda guidelines components of antenatal care. Regression modeling was used to determine factors associated with receipt of all seven components.

RESULTS

Over three fifths (65.0%) had at least one ANC visit during current or most recent pregnancy. Fewer than a quarter of women who reported attending care at least four times received all seven ANC components [(23.6%), P < 0.05]. Women who reported receipt of ANC from the mainland were twice as likely to have received all seven components as those who received care from islands (aOR = 1.8; 95% CI:0.9-3.7). Receipt of care from a doctor was associated with thrice likelihood of receiving all components relative to ANC by a midwife or nurse (aOR = 3.2; 95% CI:1.1-9.1).

CONCLUSIONS

We observed that the delivery of antenatal care components per Ugandan guidelines is poor in these communities. Cost effective endeavors to improve components of antenatal care received by women are urgently needed. Task shifting some components of ANC to community health workers may improve care in these island communities.

TRIAL REGISTRATION

PACTR201903906459874 (Retrospectively registered).

Uptake of intermittent preventive treatment for malaria during pregnancy with Sulphadoxine-Pyrimethamine in Malawi after adoption of updated World Health Organization policy: an analysis of demographic and health survey 2015-2016

Background

Malawi adopted the 2012 updated Word Health Organization (WHO) Intermittent preventive treatment of malaria during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) policy in 2013. This study aimed to estimate the proportion of and identify factors associated with the uptake of at least three doses of IPTp with SP among pregnant women in Malawi after the adoption and operationalisation of updated WHO IPTp-SP policy.

Methods

The 2015–16 Malawi Demographic and Health Survey dataset was analysed. Of 1219 women aged 15–49 years who had live births and the children were born after the date of July 2015, 1069 women were included in the analysis. Bivariate and multiple logistic regression were used in data analysis. The statistical analysis took into account a complex survey sample design.

Results

Of the 1069 women, 447 (42, 95% CI: 38.1–45.6) received three (optimal) or more doses of IPTp-SP. Less than half (47%) managed to attend at least four antenatal care (ANC) clinics. Only 52% received optimal SP doses among those who made at least four ANC visits. Only the number of ANC visits was associated with the optimal uptake of SP. Women who attended ANC three times only and those who visited ANC once or twice only were less likely to receive at least three doses of SP than those who managed to attend ANC at least four times during pregnancy (AOR = 0.71, 95% CI 0.49–1.02) and (AOR = 0.12, 95% CI 0.06–0.21) respectively.

Conclusions

To achieve effective malaria prevention in pregnancy, IPTP-SP is used alongside other interventions. However, there is low uptake of optimal SP doses in Malawi, and this seems to be associated with the number of ANC visits. Moreover, there is limited effectiveness of an increased number of ANC visits on the uptake of optimal SP doses. Further research should be done to explore health systems factors affecting uptake of optimal IPTp with SP doses during pregnancy.

Population-Based Estimation of the Preterm Birth Rate in Lilongwe, Malawi: Making Every Birth Count

Objective  The objective of this study was to perform a population-based estimation of the preterm birth (PTB) rate in regions surrounding Lilongwe, Malawi. Study Design  We partnered with obstetrician specialists, community health workers, local midwives, and clinicians in a 50 km region surrounding Lilongwe, Malawi, to perform a population-based estimation of the PTB rate during the study period from December 1, 2012 to May 19, 2015. Results  Of the 14,792 births captured, 19.3% of births were preterm, including preterm early neonatal deaths. Additional PTB risk factors were similarly prevalent including domestic violence, HIV, malaria, anemia, and malnutrition. Conclusion  When performing a population-based estimation of the rate of PTB, including women without antenatal care and women delivering at home, the 19.3% rate of PTB is among the highest recorded globally. This is accompanied by a high rate of risk factors and comorbid conditions.

Malaria during pregnancy and newborn outcome in an unstable transmission area in Brazil: A population-based record linkage study

BACKGROUND

Malaria in pregnancy (MiP) is one of the major causes of mortality and morbidity in tropical regions, causing maternal anemia, intrauterine growth retardation, preterm birth, and low birth weight (LBW). The integration of the information systems on pregnancy and malaria could prove to be a useful method of improved decision making for better maternal-child health.

METHODS

A population-based observational study acquired information retrospectively from all live births that occurred between 2006 and 2014 in Cruzeiro do Sul (Acre, Brazil). Social and clinical data of the mother and newborn was extracted from the Information System of Live Births. Malaria episodes information was obtained from the Brazilian Epidemiological Surveillance Information System Malaria. A deterministic record linkage was performed to assess malaria impact on pregnancy.

RESULTS

The studied population presented a malaria incidence of 8.9% (1283 pregnant women infected), of which 63.9% infected by Plasmodium (P.) vivax. Reduction of newborn birth weight at term (small for gestational age (SGA) and LBW) has been found associated with P. vivax infection during pregnancy (SGA-OR 1.24, 95% CI 1.02-1.52, p = 0.035; term LBW-OR 1.39, 95% CI 1.03-1.88, p = 0.033). Additionally, P. falciparum infection during pregnancy has been found to be associated with preterm births (OR 1.54, 95% CI 1.09-2.18, p = 0.016), which is related with late preterm births (OR 1.59, 95% CI 1.11-2.27, p = 0.011).

CONCLUSIONS

Despite the decrease of malaria cases during the evaluation period and regardless of Plasmodium species, we present evidence of the deleterious effects of MiP in a low transmission area in the Amazonian region.

Uptake of intermittent preventive treatment for malaria during pregnancy with Sulphadoxine-Pyrimethamine (IPTp-SP) among postpartum women in Zomba District, Malawi: a cross-sectional study

BACKGROUND

Malaria in pregnancy causes adverse birth outcomes. Intermittent preventive treatment of malaria during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) is recommended as a chemoprevention therapy. Zomba district IPTp uptake falls far below the national average. The study was conducted to assess determinants of IPTp-SP uptake during pregnancy among postpartum women in Zomba district after adoption of new IPTp-SP policy in 2014.

METHODS

This was a cross-sectional survey. Two public health facilities (HFs) were randomly selected from urban and rural areas in Zomba district. Study participants were postpartum women selected by using exit poll method from HFs. A total of 463 postpartum women were interviewed using structured questionnaire. Bivariate and multiple logistic regression was used in data analysis.

RESULTS

Out of all the enrolled participants (n = 463), 92% women had complete information for analysis. Of these, (n = 426) women, 127 (29.8%, 95% CI: 25.6%-34.3%) received three or more doses of SP, 299 (70.2%, 95% CI: 65.7%-74.4%) received two or less doses. Women receiving SP from rural HF were less likely to get at least three doses of SP than urban women, (AOR = 0.31, 95% CI 0.13-0.70); Others less likely were those with three or few antenatal care (ANC) visits versus four or more visits (AOR = 0.29, 95% CI 0.18-0.48); not taking SP under direct observation therapy (DOT) (AOR = 0.18, 95% CI (0.05-0.63).

CONCLUSIONS

There is low utilisation of at least three doses of SP in this population and this seems to be associated with the number of ANC visits and use of DOTs. These determinants may therefore be important in shaping interventions aimed at increasing the uptake of IPTp in this district. In addition, the rural urban differential suggests the need for further research to understand the barriers and enablers of uptake in each context in order to improve the health of the community.

Pharmacokinetics of co-formulated mefloquine and artesunate in pregnant and non-pregnant women with uncomplicated Plasmodium falciparum infection in Burkina Faso

OBJECTIVES

Mefloquine/artesunate has recently been developed as a fixed-dose combination, providing a promising rescue/alternative treatment for malaria during pregnancy. However, limited data are available on the effect of pregnancy on its pharmacokinetic properties. This study was conducted to assess the pharmacokinetic properties of mefloquine/carboxymefloquine and artesunate/dihydroartemisinin in pregnant and non-pregnant women with uncomplicated malaria.

METHODS

Twenty-four women in their second and third trimesters of pregnancy and 24 paired non-pregnant women were enrolled. All patients were treated for uncomplicated Plasmodium falciparum malaria with a standard fixed-dose combination of oral mefloquine and artesunate one daily over 3 days. Frequent blood samples were collected before treatment and at scheduled times post-dose for the drug measurements and pharmacokinetic analyses. The study was registered at www.clinicaltrials.gov (identifier: NCT00701961).

RESULTS

The total median exposure to mefloquine and dihydroartemisinin was not significantly different between the pregnant and non-pregnant women (P>0.05). There was a trend of higher exposure to mefloquine in the pregnant women, but this difference did not reach statistical significance (656700 versus 542400 h × ng/mL; P=0.059). However, the total exposure to carboxymefloquine was 49% lower during pregnancy (735600 versus 1499000 h × ng/mL; P<0.001) and the total drug exposure to artesunate was 42% higher during pregnancy (89.0 versus 62.9 h × ng/mL; P=0.039) compared with non-pregnant controls.

CONCLUSIONS

The plasma levels of mefloquine and dihydroartemisinin appeared to be similar in both pregnant and non-pregnant women, but there were significant differences in carboxymefloquine and artesunate exposure. The data presented here do not warrant a dose adjustment in pregnant patients, but an extensive analysis of the data could provide a better understanding of these findings.

Perceptions of intermittent preventive treatment of malaria in pregnancy (IPTp) and barriers to adherence in Nasarawa and Cross River States in Nigeria

Background

Malaria during pregnancy is dangerous to both mother and foetus. Intermittent preventive treatment of malaria in pregnancy (IPTp) is a strategy where pregnant women in malaria-endemic countries receive full doses of sulphadoxine-pyrimethamine (SP), whether or not they have malaria. The Nigerian government adopted IPTp as a national strategy in 2005; however, major gaps affecting perception, uptake, adherence, and scale-up remain.

Methods

A cross-sectional study was conducted in peri-urban and rural communities in Nasarawa and Cross River States in Nigeria. Study instruments were based on the socio-ecological model and its multiple levels of influences, taking into account individual, community, societal, and environmental contexts of behaviour and social change. Women of reproductive age, their front-line care providers, and (in Nasarawa only) their spouses participated in focus group discussions and in-depth individual interviews. Facility sampling was purposive to include tertiary, secondary and primary health facilities.

Results

The study found that systems-based challenges (stockouts; lack of provider knowledge of IPTp protocols) coupled with individual women’s beliefs and lack of understanding of IPT contribute to low uptake and adherence. Many pregnant women are reluctant to seek care for an illness they do not have. Those with malaria often prefer to self-medicate through drug shops or herbs, though those who seek clinic-based treatment trust their providers and willingly accept medicine prescribed.

Conclusions

Failing to deliver complete IPTp to women attending antenatal care is a missed opportunity. While many obstacles are structural, programmes can target women, their communities and the health environment with specific interventions to increase IPTp uptake and adherence.

Factors associated with utilization of sulphadoxine-pyrimethamine during pregnancy among women in Kenya: a cross-sectional study

The effectiveness of sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment during pregnancy for malaria is well established. However, adherence to recommended guidelines remains poor. This study examines factors related to receipt of SP among pregnant women in Kenya. Descriptive and inferential statistics for complex survey data were utilized using the 2008-2009 Kenya Demographic and Health Survey. With the exception of women residing in Nyanza, women who reside in other provinces were more likely to receive one dose of SP versus none compared to women living in Nairobi. Women receiving antenatal care from a nurse or midwife and women who owned a bed net were almost twice as likely to receive one dose of SP versus none (aOR 1.92, 95% CI 1.28, 2.86 and aOR 1.79; 95% CI 1.12, 2.78; respectively); whereas, women who received other anti-malarial drugs were over 90% less likely to receive one dose of SP versus none (aOR 0.08; 95% CI 0.02, 0.26). Among women who receive any SP, increased numbers of antenatal care visits were associated with receipt of two or more doses of SP (aOR 1.16; 95% CI 1.02, 1.32-per additional visit), while women living in the western province were nearly 75% less likely to receive two or more doses compared to women in Nairobi (aOR 0.27; 95% CI 0.08, 0.94). Receipt of the recommended ≥2 doses of SP is associated with predisposing and enabling characteristics. Further research is needed to identify barriers to receiving SP during pregnancy.

The Placenta in Toxicology. Part II

During pregnancy, the maternal immune system is challenged by the semiallogeneic fetus, which must be tolerated without compromising fetal or maternal health. This review updates the systemic and local immune changes taking place during human pregnancy, including some examples in rodents. Systemic changes are induced by contact of maternal blood with placental factors and include enhanced innate immunity with increased activation of granulocytes and nonclassical monocytes. Although a bias toward T helper (Th2) and regulatory T cell (Treg) immunity has been associated with healthy pregnancy, the relationship between different circulating Th cell subsets is not straightforward. Instead, these adaptations appear most evidently at the fetal–maternal interface, where for instance Tregs are enriched and promote fetal tolerance. Also innate immune cells, that is, natural killer cells and macrophages, are enriched, constituting the majority of decidual leukocytes. These cells not only contribute to immune regulation but also aid in establishing the placenta by promoting trophoblast recruitment and angiogenesis. Thus, proper interaction between leukocytes and placental trophoblasts is necessary for normal placentation and immune adaptation. Consequently, spontaneous maladaptation or interference of the immune system with toxic substances may be important contributing factors for the development of pregnancy complications such as preeclampsia, preterm labor, and recurrent miscarriages.

Congenital and oral transmission of American trypanosomiasis: an overview of physiopathogenic aspects

Chagas disease or American trypanosomiasis is a pathology affecting about 8-11 million people in Mexico, Central America, and South America, more than 300 000 persons in the United States as well as an indeterminate number of people in other non-endemic countries such as USA, Spain, Canada and Switzerland. The aetiological agent is Trypanosoma cruzi, a protozoan transmitted by multiple routes; among them, congenital route emerges as one of the most important mechanisms of spreading Chagas disease worldwide even in non-endemic countries and the oral route as the responsible of multiple outbreaks of acute Chagas disease in regions where the vectorial route has been interrupted. The aim of this review is to illustrate the recent research and advances in host-pathogen interaction making a model of how the virulence factors of the parasite would interact with the physiology and immune system components of the placental barrier and gastrointestinal tract in order to establish a response against T. cruzi infection. This review also presents the epidemiological, clinical and diagnostic features of congenital and oral Chagas disease in order to update the reader about the emerging scenarios of Chagas disease transmission.

Ten year trend analysis of malaria prevalence in Kola Diba, North Gondar, Northwest Ethiopia

BACKGROUND

Malaria is caused by protozoan parasites of the genus Plasmodium. It is one of the leading causes of illness and death in the world. It is a major public health problem in Ethiopia. Over the past years, the disease has been consistently reported as the first leading cause of outpatient visits, hospitalization and death in health facilities across the country.

METHODS

A retrospective study was conducted to determine the prevalence of malaria from peripheral blood smear examinations from the Kola Diba Health Center of Ethiopia. The case notes of all malaria cases reported between 2002-2011 were carefully reviewed and analyzed. Additionally, any malaria intervention activities that had been taken to control malaria were collected using a well-prepared checklist from the study area.

RESULTS

Within the last decade (2002-2011) a total of 59, 208 blood films were requested for malaria diagnosis in Kola Diba health center and 23,473 (39.6%) microscopically confirmed malaria cases were reported in the town with a fluctuating trend. Regarding the identified plasmodium species, Plasmodium falciparum and Plasmodium vivax accounted for 75% and 25% of malaria morbidity, respectively. Malaria was reported in all age groups and both sexes, but the 15-44 year age group and males were more affected. Despite the apparent fluctuation of malaria trends in the area, the highest peak of malaria cases was reported during spring seasons.

CONCLUSION

Comparatively, after the introduction of the current malaria control strategies, the morbidity and mortality by malaria is decreasing but malaria is still a major health problem and the deadly species P. falciparium is predominant. Therefore, control activities should be continued in a strengthened manner in the study area considering both P. falciparium and P. vivax.

Patterns of case management and chemoprevention for malaria-in-pregnancy by public and private sector health providers in Enugu state, Nigeria

Background

Malaria in pregnancy (MIP) is a major disease burden in Nigeria and has adverse consequences on the health of the mother, the foetus and the newborn. Information is required on how to improve its prevention and treatment from both the providers’ and consumers’ perspectives.

Methods

The study sites were two public and two private hospitals in Enugu, southeast Nigeria. Data was collected using a pre-tested structured questionnaire. The respondents were healthcare providers (doctors, pharmacists and nurses) providing ante-natal care (ANC) services. They consisted of 32 respondents from the public facilities and 20 from the private facilities. The questionnaire elicited information on their: knowledge about malaria, attitude, chemotherapy and chemoprophylaxis using pyrimethamine, chloroquine proguanil as well as IPTp with sulphadoxine-pyrimethamine (SP). The data was collected from May to June 2010.

Results

Not many providers recognized maternal and neonatal deaths as potential consequences of MIP. The public sector providers provided more appropriate treatment for the pregnant women, but the private sector providers found IPTp more acceptable and provided it more rationally than public sector providers (p < 0.05). It was found that 50 % of private sector providers and 25 % of public sector providers prescribed chemoprophylaxis using pyrimethamine, chloroquine and proguanil to pregnant women.

Conclusions

There is sub-optimal level of knowledge about current best practices for treatment and chemoprophylaxis for MIP especially in the private sector. Also, IPTp was hardly used in the public sector. Interventions are required to improve providers’ knowledge and practices with regards to management of MIP.

Sulfadoxine-pyrimethamine resistance and intermittent preventive treatment during pregnancy: a retrospective analysis of birth weight data in the Democratic Republic of Congo (DRC)

OBJECTIVE

To assess the effect of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) on birth weight in sites with varying degrees of drug resistance.

METHODS

Birth weight data from three regions in Democratic Republic of Congo with varying degrees of sulfadoxine-pyrimethamine (SP) resistance (1.6% in Mikalayi, 21.7% in Kisangani and 60.6% in Rutshuru) were analysed retrospectively by means of a logistic model that included the number of SP doses taken by the mother and other potentials confounding factors.

RESULTS

The IPTp-SP reduced the risk of low birth weight (LBW) in Kisangani (adjusted OR, 0.15; IC95%, 0.05-0.46) and in Mikalayi (adjusted OR, 0.12; IC95%, 0.01-0.89). In both sites, the average birth weight was higher for mothers having received two rather than one or no SP doses (P < 0.001). In Rutshuru, IPTp-SP had an effect in primigravidae but not in multigravidae. However, after adjustment for other LBW risk factors, there was no difference in the proportion of LBW (adjusted OR 0.92; IC95%, 0.37-2.25) between women having taken at least 2 SP doses and those with only one dose or none.

CONCLUSION

IPT-SP remains an effective strategy in Kisangani and Mikalayi where the therapeutic failure to SP in children with clinical malaria was 21.7% and 1.6%, respectively, while IPTp-SP effect seems lower in Rutshuru where the therapeutic failure to SP was 60.6%. The threshold value of SP resistance at which IPTp-SP fails to have a significant impact on birth weight and LBW is unknown. Considering that no alternative is currently available, additional studies on the efficacy of IPTp-SP in the areas of high SP resistance such as Rutshuru are needed so that the threshold at which this intervention fails to provide any benefit is determined with some precision.

Diagnosis of gestational, congenital, and placental malaria in Colombia: comparison of the efficacy of microscopy, nested polymerase chain reaction, and histopathology

The technical capability of different methods to diagnose Plasmodium in maternal peripheral blood, placenta, and umbilical cord blood has not been assessed in Colombia and seldom explored in other malaria-endemic regions. We designed a study to compare the technical and the operational-economical performances of light microscopy (LM), nested polymerase chain reaction (nPCR), and histopathology (HP). In maternal blood, LM had 41% sensitivity and 100% specificity and in placental blood, 35% and 100%, respectively, compared with nPCR. In placental tissue, LM had 33% sensitivity and 95% specificity; and nPCR 47% and 77%, respectively; compared with HP. Light microscopy had the best operational-economical qualification. We concluded that nPCR and HP performed better compared with LM, but field implementation of these two techniques remains a problem. Therefore, LM is recommended as the gold standard for diagnosis of gestational malaria and placental blood infection in the field.

The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania

Background

Intermittent preventive treatment during pregnancy (IPTp) at routine antenatal care (ANC) clinics is an important and efficacious intervention to reduce adverse health outcomes of malaria infections during pregnancy. However, coverage for the recommended two IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage.

Methods

Data on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Women's timing of ANC visits and health worker's timing of IPTp delivery were analyzed in relation to the different national IPTp schedules and the outcome on IPTp coverage was modelled.

Results

Among all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. Less than 1% of women started ANC attendance after 32 weeks of gestation. During the second IPTp delivery period health workers delivered IPTp to significantly less women than during the first one (55% vs. 73%) contributing to low second dose coverage. Simplified IPTp guidelines for front-line health workers as recommended by WHO could lead to a 20 percentage point increase in IPTp coverage.

Conclusions

This study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. To maximize the benefit of the IPTp intervention, revision of existing guidelines is needed. Training on simplified IPTp messages should be consolidated as part of the extended antenatal care training to change health workers' delivery practices and increase IPTp coverage. Pregnant women's knowledge about IPTp and the risks of malaria during pregnancy should be enhanced as well as their ability and power to demand IPTp and other ANC services.

New adjuvanted vaccines in pregnancy: what is known about their safety?

The recent introduction of oil-in-water emulsions as adjuvants in several pandemic vaccines, such as the H1N1 vaccine, has challenged regulatory authorities to establish their safety in the general population, as well as in specific populations. Pregnant women were advised to be a target group for H1N1 vaccination owing to the risk of this group developing serious complications with this infection. However, the addition of adjuvants to the H1N1 vaccine has initiated a discussion on the safety of adjuvanted vaccines in this special population. Changes in the maternal immune system are essential for acceptance of the fetus and for development of the placenta. The potential effects on pregnancy of interfering with this uniquely adapted immune balance through the induction of proinflammatory reactions such as those induced by adjuvanted vaccines have only been studied rarely. Here, we review the available information and discuss how vaccination may interfere with pregnancy, fetal development and pregnancy outcomes.

Intermittent preventive treatment of malaria with sulphadoxine-pyrimethamine during pregnancy in Burkina Faso: effect of adding a third dose to the standard two-dose regimen on low birth weight, anaemia and pregnancy outcomes

Background

Intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) is being implemented in most malaria endemic countries as a standard two-doses regimen as it reduces the risk of low birth weight (LBW) and the prevalence of maternal anaemia. Nevertheless, where the risk of infection close to delivery is high because of intense transmission, a third IPTp-SP dose may further reduce the negative effects of malaria on pregnancy outcome.

Methods

Pregnant women in the 2^nd or 3^rd trimester were randomized to receive either 2 (SP2) or 3 doses (SP3) of SP. Trained field workers paid home visits to the women for drug administration according to a predefined drug delivery schedule. Women were encouraged to attend their scheduled ANC visits and to deliver at the health facilities where the new-born was weighed. The prevalence of LBW (<2500 g), severe anaemia (Hb < 8 g/dL) and premature birth was analysed using intention-to-treat (ITT) and per-protocol (PP) analysis.

Results

Data from 1274 singleton pregnancies were analysed (641 in the SP3 and 633 in the SP2 group). The uptake of the intervention appeared to be low. Though the prevalence of LBW in both intervention groups was similar (adjusted Incident Rate Ratio, AIRR = 0.92, 95%CI: 0.69-1.24) in the ITT analysis, the risk of severe anaemia was significantly lower in the SP3 group compared to the SP2 group (AIRR = 0.38, 95%CI: 0.16 - 0.90). The PP analysis showed a trend of reduced risk of LBW, severe anaemia and premature delivery in the SP3 group, albeit the difference between two and three IPTp-SP did not reach statistical significance.

Conclusion

The risk of LBW and severe anaemia tended to be lower in the SP3 group, though this was not statistically significant, probably due to the low uptake of the intervention which reduced the power of the study. Further studies are needed for establishing whether a third SP dose has a real benefit in preventing the negative effects of malaria in pregnancy in settings where transmission is markedly seasonal.

Importance of nonenteric protozoan infections in immunocompromised people

There are many neglected nonenteric protozoa able to cause serious morbidity and mortality in humans, particularly in the developing world. Diseases caused by certain protozoa are often more severe in the presence of HIV. While information regarding neglected tropical diseases caused by trypanosomatids and Plasmodium is abundant, these protozoa are often not a first consideration in Western countries where they are not endemic. As such, diagnostics may not be available in these regions. Due to global travel and immigration, this has become an increasing problem. Inversely, in certain parts of the world (particularly sub-Saharan Africa), the HIV problem is so severe that diseases like microsporidiosis and toxoplasmosis are common. In Western countries, due to the availability of highly active antiretroviral therapy (HAART), these diseases are infrequently encountered. While free-living amoebae are rarely encountered in a clinical setting, when infections do occur, they are often fatal. Rapid diagnosis and treatment are essential to the survival of patients infected with these organisms. This paper reviews information on the diagnosis and treatment of nonenteric protozoal diseases in immunocompromised people, with a focus on patients infected with HIV. The nonenteric microsporidia, some trypanosomatids, Toxoplasma spp., Neospora spp., some free-living amoebae, Plasmodium spp., and Babesia spp. are discussed.

Immunology of pregnancy

The conceptual framework for reproductive immunology was put in place over 50 years ago when the survival of the fetal semi-allograft within an immunocompetent mother was first considered. During this time, a number of paradigms have emerged and the mechanisms receiving current attention are those related to immune tolerance, such as regulatory T-cells and indoleamine 2,3,-dioxygenase, and innate immunity, such as natural killer cells, trophoblast debris and inflammation. A key consideration is the temporal and spatial variation in any of these pathways (e.g. implantation v. parturition). As fetally derived trophoblasts are the semi-allogeneic cells with which the maternal immune system comes into contact, understanding the immune response to these cells is critical. There is much interest in the immunological pathways that support a healthy pregnancy and how they might be perturbed in adverse pregnancy outcomes. Additionally, there is increasing awareness that antenatal determinants of the immune function of pregnant women and their offspring have consequences for health and disease in childhood and beyond. Changes in maternal diet over recent decades coincide with the increasing prevalence of allergic and other immune-mediated diseases, and the modification of maternal diet has emerged as a strategy for disease prevention. Approaches undergoing trial at numerous sites around the world include dietary supplementation with fish oil and/or probiotics. Understanding the underlying mechanisms of any positive effect on disease outcomes should reveal further novel strategies for disease prevention.

Reducing stillbirths: prevention and management of medical disorders and infections during pregnancy

BACKGROUND

An estimated two-thirds of the world's 3.2 million stillbirths occur antenatally, prior to labour, and are often overlooked in policy and programs. Poorly recognised, untreated or inadequately treated maternal infections such as syphilis and malaria, and maternal conditions including hypertensive disorders, are known risk factors for stillbirth.

METHODS

We undertook a systematic review of the evidence for 16 antenatal interventions with the potential to prevent stillbirths. We searched a range of sources including PubMed and the Cochrane Library. For interventions with prior Cochrane reviews, we conducted additional meta-analyses including eligible newer randomised controlled trials following the Cochrane protocol. We focused on interventions deliverable at the community level in low-/middle-income countries, where the burden of stillbirths is greatest.

RESULTS

Few of the studies we included reported stillbirth as an outcome; most that did were underpowered to assess this outcome. While Cochrane reviews or meta-analyses were available for many interventions, few focused on stillbirth or perinatal mortality as outcomes, and evidence was frequently conflicting. Several interventions showed clear evidence of impact on stillbirths, including heparin therapy for certain maternal indications; syphilis screening and treatment; and insecticide-treated bed nets for prevention of malaria. Other interventions, such as management of obstetric intrahepatic cholestasis, maternal anti-helminthic treatment, and intermittent preventive treatment of malaria, showed promising impact on stillbirth rates but require confirmatory studies. Several interventions reduced known risk factors for stillbirth (e.g., anti-hypertensive drugs for chronic hypertension), yet failed to show statistically significant impact on stillbirth or perinatal mortality rates. Periodontal disease emerged as a clear risk factor for stillbirth but no interventions have reduced stillbirth rates.

CONCLUSION

Evidence for some newly recognised risk factors for stillbirth, including periodontal disease, suggests the need for large, appropriately designed randomised trials to test whether intervention can minimise these risks and prevent stillbirths. Existing evidence strongly supports infection control measures, including syphilis screening and treatment and malaria prophylaxis in endemic areas, for preventing antepartum stillbirths. These interventions should be incorporated into antenatal care programs based on attributable risks and burden of disease.